New Diagnostic Codes Catalyzing Market Creation

Every few years, CMS introduces new CPT codes that redefine reimbursable care pathways. This transforms previously out-of-pocket or unbillable workflows - reducing friction for adoption, increasing patient access, and creating quantifiable ROI for payers. The next generation of enduring healthcare businesses will be built by founders who identify and operationalize these code-enabled frontiers before incumbents catch on:

• Remote Patient Monitoring & Hospital-at-Home: Reimbursement expansion is redefining where care happens, shifting inpatient encounters into reimbursable home-based models and creating durable recurring revenue for monitoring and logistics platforms. (Conduit, Teton, Inspiren)
• Patient Advocacy: New codes now reimburse care navigation and social determinant screening, legitimizing patient advocacy as a scalable business model, creating space for companies that combine human advocates with software to guide patients through fragmented systems. (Solace) 
• Functional Medicine & Integrative Medicine: Preventive and multi-disciplinary care models - nutrition, behavioral, and lifestyle (including via embedded D2C apps) - are gaining reimbursement recognition, opening the door for software that standardizes and tracks holistic care protocols.
• AI-Powered Prior Authorization and Coding Automation: As billing complexity explodes with each new code, AI automation becomes increasingly critical. Platforms that translate physician notes and diagnostic inputs into compliant, optimized claims can capture enormous value through denial reduction and efficiency gains.  (Latent, Tandem, Mandolin)

… and the list goes on - new codes are quietly opening up entire markets across digital mental health, genetic testing, AI-assisted radiology and pathology, preventive social determinant screening, and remote rehabilitation. Each represents a wedge where reimbursement is catching up to clinical innovation, and where founders can turn regulatory tailwinds into enduring infrastructure.

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The New Pharma Coordination Layer

Every specialty therapy requires coordination across four entities: the prescriber, the insurer, the pharmacy, and the manufacturer. Each has its own systems, incentives, and compliance workflows - and most of the coordination still happens over phone calls, faxes, and spreadsheets. This creates a massive opportunity for startups to re-architect the entire plumbing behind drug coordination - building next-gen systems that manage access, coverage, prior authorizations, financial assistance, and refill logistics at scale.

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• AI-Powered Prescription Access Platforms: Streamlining insurance checks, prior authorizations, and copay programs, standardizing payer communication and cutting time-to-therapy.
• Care Coordination for Specialty Therapies: Specialty drugs require multi-party follow-up, often managed by nurses or field reps. AI-driven communication tools can digitize post-prescription workflows (onboarding, labs, infusions, monitoring), turning multi-party coordination into a single automated process.
• Voice-Driven Interactions: Much of the pharma-to-provider interaction still happens over phone, like verifying benefits or confirming coverage. Voice AI and automated compliance documentation can transform this workflow - think “pharma voice agents” built on domain-specific language models.
• Manufacturer–Prescriber Marketplaces: Pharma manufacturers are incentivized to ensure their therapies are prescribed correctly and efficiently. A marketplace that aligns prescribers and manufacturers - surfacing therapy options based on coverage eligibility, patient criteria, and access programs - could provide clear ROI for pharma sales teams.
• Pharmacy Infrastructure & 340B Optimization: Pharmacies are sitting on billions in unrealized rebate and 340B optimization potential due to opaque data and manual contracting. Platforms that integrate rebates, 340B compliance tracking, and manufacturer discount programs into a unified analytics and contracting layer could unlock meaningful margin.

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Modernizing the Front Office of Healthcare

We continue to believe that LLMs are collapsing the cost of cognition in healthcare administration. Tasks that once required large, outsourced human teams can now be replicated or exceeded with an API call. This unlocks a new generation of software that makes patient experiences seamless and allows small and mid-size practices to operate with enterprise-level efficiency, in categories around: 

• Smart patient intake: streamlines demographic capture, insurance verification, and consent workflows.
• Adaptive scheduling: optimizes appointments, reschedules, and resource allocation in real time.
• Automated care coordination: closes the loop on labs, referrals, and follow-ups across care teams.
• Voice-driven support centers: handles inbound calls, triage, and post-visit summaries with natural dialogue.
• End-to-end practice copilots: integrates scheduling, billing, and communications into a unified dashboard.
• Billing and documentation automation: translates visit notes into compliant claims and chart entries instantly.

Patient engagement & retention: personalizes reminders, follow-ups, and educational touchpoints to improve adherence.